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Daniel S. Behroozan, MD,a and Leonard H. Goldberg, MD, FRCPa,b
by Kleinin 1987 when he detailed the infil-
bicarbonate. A 30-gauge, .5-in needle on a 3-mL sy-
tration of large volumes of a diluted solution
ringe is used to inject the anesthetic. Only the tip of
of lidocaine with epinephrine into fat before lipo-
the needle is inserted into the papillary dermis at
suction. The tumescent technique revolutionized
approximately a 30-degree angle. The solution is
liposuction by eliminating the necessity of general
injected slowly to allow diffusion of anesthesia
anesthesia or intravenous sedation and the copious
within the dermis and not increase the intradermal
bleeding that had been associated with liposuction
tissue pressure. Care is taken not to inject anesthetic
procedures. Since that time, the use of the tumescent
technique has been expanded to include other der-
Initially, one observes a blanching phenomenon
matologic surgical procedures such as hair trans-
as a result of mechanical compression of dermal
plantation, laser surgery, face-lifts, abdominoplasty,
vessels. Further injection of anesthetic solution leads
to the elevation of a bleb and peau d’orange as the
The benefits of the tumescent technique detailed
anesthetic material swells the dermis locally while
by Kleinare numerous: optimizing biochemical
diffusing laterally (When injecting within the
drug efficacy, targeting drug effects in local tissue
dermis, as compared with injecting into the subcu-
compartments, maximizing drug concentration lo-
taneous tissue, there is an elevated level of resistance
cally, delaying systemic drug absorption, prolonging
that is felt on the syringe plunger.
local and systemic drug effects, decreasing systemic
While injecting the anesthetic solution, every
drug toxicity, increasing the safe upper limit of drug
attempt is made to minimize pain by slow injection,
dosage, mechanically expanding a targeted com-
using buffered anesthesia, and continual verbal dis-
partment, and benefiting from augmented local
traction and reassurance to the patient ().
hydrostatic pressure to reduce bleeding.
Additional needle sticks are minimized as the anes-
In this report, we aim to describe the use of dermal
thetic solution readily diffuses through the dermis.
tumescent anesthesia in cutaneous surgical procedures.
When needed to provide a larger area of anesthesia,
It is the authors’ experience that dermal tumescent
further injections should be made through already
anesthesia produces superior local anesthesia by
directly injecting larger amounts of diluted anestheticsolution into the dermis, and also a reduced amount
of bleeding intraoperatively and postoperatively.
The technique described above for dermal tu-
mescent anesthesia provides the skin surgeon with a
temporarily bloodless dermal field and exquisite
We routinely use a commercially available solu-
anesthesia to perform surgical procedures ().
tion of 0.5% lidocaine with epinephrine 1:200,000
This procedure for the delivery of local dermalanesthesia is a modification of routinely taughtmethods of infiltration of local anesthesia into the
From DermSurgery Associates,a and Department of Medicine (Der-
matology), University of Texas, MD Anderson Cancer Center.b
The use of dermal tumescent anesthesia results in
Funding sources: None.
Conflicts of interest: None identified.
lesser amounts of anesthetic solution injected into
Reprint requests: Leonard H. Goldberg, MD, FRCP, DermSurgery
the dermis compared with when injecting directly
Associates, 7515 Main, Suite 240, Houston, TX 77030.
into fat to obtain adequate anesthesia. There are
several benefits for the surgeon and patient by using
this technique. There is immediate mechanical com-
2005 by the American Academy of Dermatology, Inc.
pression of vascular structures even before the effect
of epinephrine takes place. This, combined with the
Fig 1. Demonstration of insertion of needle at 30-degree
Fig 3. Dermal tumescent anesthesia provides temporarily
angle to produce dermal tumescent anesthesia.
bloodless field; 10 mL of local anesthetic solution was usedfor tumescence of each field.
Fig 4. Five minutes of postoperative pressure rather than
Fig 2. Dermal blanching and peau d’orange formation as
electrocautery is often sufficient for complete hemostasis
anesthesia swells dermis locally while diffusing laterally.
more dilute concentration of epinephrine in the
Table I. Tips to reduce pain during dermal
anesthetic solution, is especially important with
elderly patients and those who are more sensitive
to the cardiac effects of adrenaline. In addition, using
2. Insert only the tip of the needle initially
reduced concentrations of lidocaine and epineph-
3. Use a 30-gauge, .5-in needle on a 3-mL syringe
rine allows one to inject more anesthetic solution to
maximize tumescence. It should be noted that when
5. Continually distract the patient with verbal reassurance
injecting into the dermis, the volume of fluid injected
is less than when anesthetic solution is routinely
6. Additional injections should be made through already
injected into the fat. We routinely inject an average of
10 mL intradermally for a 1-cm tumor.
Increased tissue pressure caused by anesthetic
fluid injected into the dermis compresses bloodvessels resulting in reduced bleeding during surgical
necrosis and eschar formation, and potentially de-
procedures with less need for electrocautery for
creases the likelihood of postoperative infections.
hemostasis. In fact, it is the authors’ experience that
It should be noted that in operations below the
after surgical or Mohs micrographic surgical exci-
level of the dermis, such as excision of lipomas that
sions using the dermal tumescent technique, post-
may extend and penetrate more deeply, it is impor-
operative pressure alone rather than electrocautery
tant to follow intradermal injection with subcutane-
is often sufficient for complete hemostasis for
ous infiltration to provide more complete local
wounds (). The lack of need to use excessive
anesthesia, although solution from dermal injection
electrocautery during routine dermatologic surgical
diffuses into the upper fat for some degree of
procedures reduces operative time, decreases tissue
anesthesia. In addition, for excisional surgeries
requiring extensive undermining in the subcutane-
In conclusion, we describe a modified form of
ous plane, subcutaneous infiltration beyond the area
delivery of local anesthesia into the dermis that
of initial dermal tumescence site will be necessary.
provides a rapid onset of anesthesia, provides a
Yet, for excision and closure of lesions that do not
relatively bloodless field in which to operate, and
penetrate below the level of the subcutaneous fat,
requires decreased absolute amounts of local anes-
intradermal anesthesia is sufficient and beneficial in
thetic leading to increased ease of performing skin
that a decreased volume of anesthetic solution is not
lost into the subcutaneous level without benefit tothe patient. Dermal swelling after tumescent injec-
tion is lost within minutes, reducing distortion of
1. Klein JA. Tumescent technique for liposuction surgery. Am J
tissue during closure or repair. Lastly, it is the authors’
view that intradermal delivery of local anesthesia
2. Namias A, Kaplan B. Tumescent anesthesia for dermatologic
leads to a quicker onset and prolonged duration of
surgery. Dermatol Surg 1998;24:755-8.
anesthesia. This is likely a result of the fact that most
3. Krejci-Manwaring J, Markus JL, Goldberg LH, Friedman PM,
Markus RF. Surgical pearl: tumescent anesthesia reduces pain of
of the afferent pain fiber nerve endings in the skin
axillary laser hair removal. J Am Acad Dermatol 2004;51:290-1.
are in the papillary dermis and not the subcutane-
4. Klein JA. Tumescent technique chronicles: local anesthesia,
liposuction, and beyond. Dermatol Surg 1995;21:449-57.
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